Severe pre-eclampsia at 31 weeks in a district hospital without neonatal ventilation

Magnesium sulphate - the priority. She has severe features (BP ≥160/110 with symptoms, thrombocytopenia, transaminitis) and a seizure risk of roughly 1–2% untreated. Because the single pump cannot run a continuous infusion while also delivering intravenous antihypertensives, use a Pritchard-type regimen: 4 g of 20% magnesium sulphate IV over 20 minutes as the loading dose, then 10 g deep IM (5 g into each buttock as a 50% solution with 1 mL of 2% lignocaine), followed by 5 g IM into alternate buttocks every 4 hours. This frees the pump after the bolus. If Zuspan (4 g IV then 1 g/hour) is used instead, the antihypertensives must be given by intermittent bolus or orally.

Monitoring for toxicity - hourly (or more frequent) patellar reflex, respiratory rate above 12–16/min, urine output above 30 mL/hour (100 mL per 4 hours), conscious level and oxygen saturation. If reflexes are absent, respiration depressed or urine output falls, stop magnesium and give calcium gluconate 10 mL of 10% IV.

Blood pressure control - target roughly 130–150/80–100 mmHg; do not drop the mean arterial pressure abruptly because uteroplacental perfusion is already compromised by absent end-diastolic flow. Labetalol 200 mg orally then 200 mg 6–8 hourly, or nifedipine 10 mg orally repeated after 30 minutes, or hydralazine 5 mg IV increments. Avoid ACE inhibitors and diuretics unless there is pulmonary oedema.

Corticosteroids - dexamethasone 6 mg IM 12-hourly for four doses (or betamethasone 12 mg IM twice, 24 hours apart) to buy a 24–48 hour maturation window without delaying delivery if she deteriorates.

Supportive care - fluid restriction around 80 mL/hour with strict input/output charting, thromboprophylaxis once delivery is planned, group and save, and avoidance of ergometrine in the third stage.

Transfer in utero, after maternal stabilisation. At 31+2 weeks with an estimated weight of 1350 g, survival without neonatal ventilation in a district setting is poor; the single most effective intervention for this baby is delivery in a unit with level 2/3 neonatal care. Delivery here would convert a maternal problem into a combined maternal–neonatal problem.

Sequence: control the blood pressure, load magnesium, give the first dose of steroid, secure two large-bore cannulae and cross-matched blood, then move by obstetric ambulance with a midwife and doctor, continuing IM magnesium and hourly observations. Speak directly to the receiving consultant obstetrician and neonatologist before departure so a bed is confirmed - a transfer to a closed unit is worse than staying.

Transfer is unsafe - deliver locally - if: hypertension remains uncontrolled after two or three agents; she has a seizure; there is abruption or ongoing vaginal bleeding; the CTG becomes non-reassuring with late or prolonged decelerations; platelets are falling rapidly with worsening right upper quadrant pain suggesting progressive HELLP; or the road/ambulance is unavailable such that transfer would take more than about 2–4 hours.

Decision logic: severe pre-eclampsia at ≥34 weeks is delivered; below 34 weeks, expectant management is only justified in a unit that can (a) monitor mother and fetus, (b) give steroids, and (c) deliver a preterm baby safely. This unit can do only the first two. Absent end-diastolic flow also signals that the fetus will not tolerate a long delay, so the plan is transfer first, delivery within 24–48 hours at the tertiary unit, not expectant management to 34 weeks.

The situation has changed from 'severe pre-eclampsia' to 'severe pre-eclampsia with progressive HELLP plus fetal compromise in a unit that cannot transfer'. Transfer is now contraindicated during an acute deterioration; she needs delivery here, now.

Immediate actions

• Escalate: consultant obstetrician and anaesthetist, haematologist by phone, blood bank releasing all available products (two units of red cells plus fresh frozen plasma), theatre and neonatal team alerted.
• Continue magnesium sulphate for seizure prophylaxis and keep systolic BP 130–150 mmHg with IV boluses, since oral absorption is unreliable in a sick patient.
• Do not wait for the steroid course or for a bed. Repeated late decelerations with absent end-diastolic flow means the fetus is hypoxic; steroids given before 48 hours still reduce mortality and intraventricular haemorrhage but must not delay delivery.
• Mode of delivery: caesarean section under general or regional anaesthesia by the most senior operator. Platelets of 62 × 10^9/L are usually adequate for caesarean but not for an epidural; expect bleeding, have blood products in theatre, and avoid ergometrine. A vaginal birth would be preferable in a stable woman with a cephalic fetus, but not with fetal compromise and a falling platelet count.
• Anticipate HELLP complications: subcapsular liver haematoma (avoid vigorous liver retraction), acute kidney injury, pulmonary oedema (restrict fluids), and postpartum haemorrhage.

After delivery - magnesium continues for 24 hours postpartum; hypertension often worsens on days 3–5 and needs continued treatment; platelets usually recover within 72–96 hours. Debrief the family that the delay in transfer was the main modifiable factor and document the bed-search attempts.